Resumen
La cicatriz uterina es un defecto en la pared anterior del miometrio secundario a la cesárea. Su prevalencia es muy variable, llegando hasta el 84% en algunos estudios, y aumenta según el número de cesáreas previas. La mayoría de las pacientes pueden ser asintomáticas, pero cuando se manifiesta es principalmente con hemorragia uterina anormal. El manejo de esta patología se ha descrito mediante técnicas farmacológicas y quirúrgicas, siendo más estudiadas las técnicas quirúrgicas, dentro de las que se encuentran la histeroscopía, laparoscopia,laparoscopia asistida con histeroscopía, laparotomía y el abordaje vaginal. Se realizó una revisión en PubMed-MEDLINE y LILACS respecto al manejo de este defecto, tomándose artículos publicados en los últimos cinco años, en la cual se encontraron 37 artículos. El manejo depende principalmente de factores como la sintomatología de la paciente, si tiene paridad satisfecha o no, la profundidad del defecto y
las preferencias de la paciente. MÉD.UIS.2019;32(3):11-7
Referencias
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2. Departamento Administrativo Nacional de Estadística (DANE). Nacimientos 2015. Cuadro 4. Nacimientos por tipo de parto según departamento de ocurrencia y sitio del parto. 2017.
3. Tulandi T, Cohen A. Emerging manifestations of cesarean scar defect in reproductive-aged women. J Minim Invasive Gynecol. 2016;23(6):893–902.
4. Vervoort A, Van der Voet L, Hehenkamp W, Thurkow A, van Kesteren P, Quartero H, et al. Hysteroscopic resection of a uterine caesarean scar defect (niche) in women with postmenstrual spotting: a
andomised controlled trial. BJOG An Int J Obstet Gynaecol. 2018;125(3):326-334.
5. Martin JA, Hamilton BE, Osterman MJKS, Driscoll AK, Mathews TJ. National Vital Statistics Reports. 2017;66(1).
6. Organización Panamericana de la Salud, Organización Mundial de la Salud. La cesárea solo debería realizarse cuando sea medicamente necesaria. 2015.
7. Sipahi S, Sasaki K, Miller CE. The minimally invasive approach to the symptomatic isthmocele - what does the literature say? A step-by-step primer on laparoscopic isthmocele - excision and repair. Curr Opin bstet Gynecol. 2017;29(4):257–65.
8. van der Voet L (Lucet) F, Limperg T, Veersema S, Timmermans A, Bij de Vaate AMJ, Brölmann HAM, et al. Niches after cesarean section in a population seeking hysteroscopic sterilization. Eur J Obstet Gynecol Reprod Biol. 2017;214:104–8.
9. Benedetti O, Agudelo C, Rodríguez R, Miranda Á, Rodríguez H, Castro C. Prevalencia de istmocele en el Hospital de San José de Bogotá, Colombia. Rev Chil Obstet Ginecol. Sociedad Chilena de Obstetricia y Ginecología; 2016 Dec;81(6):465–72.
10. Tower AM, Frishman GN. Cesarean Scar Defects: An Underrecognized Cause of Abnormal Uterine Bleeding and Other Gynecologic Complications. J Minim Invasive Gynecol. 2013;20(5):562–72.
11. Wu X, Lin R, Yuan Y, He Y, Xu C, Hu W, et al. A comparison of the effects of two different treatment methods on cesarean section scar diverticulum: The surgical repair of cesarean scars via combined laparoscopy and hysteroscopy vs. cyclic estrogen/progesterone therapy. Int J Clin Exp Med. 2017;10(4):7144–50
12. Van Der Voet LF, Vervoort AJ, Veersema S, Bijdevaate AJ, Brölmann HAM, Huirne JAF. Minimally invasive therapy for gynaecological symptoms related to a niche in the caesarean scar: A systematic review. BJOG An Int J Obstet Gynaecol. 2014;121(2):145–56.
13. Setubal A, Alves J, Osório F, Guerra A, Fernandes R, Albornoz J, et al. Treatment for Uterine Isthmocele, a Pouch-Like Defect at the Site of Cesarean Section Scar. J Minim Invasive Gynecol. 2018;25(1):38-46.
14. Futyma K, Gałczyński K, Romanek K, Filipczak A, Rechberger T. When and how should we treat cesarean scar defect - isthmocoele? Ginekol Pol. 2016;87(9):664–8.
15. Li C, Tang S, Gao X, Lin W, Han D, Zhai J, et al. Efficacy of Combined Laparoscopic and Hysteroscopic Repair of Post- Cesarean Section Uterine Diverticulum: A Retrospective Analysis. Biomed Res Int. 2016;2016(5):1-6.
16. Zhang X, Yang M, Wang Q, Chen J, Ding J, Hua K. Prospective evaluation of five methods used to treat cesarean scar defects. Int J Gynaecol Obstet. 2016;134(3):336–9.
17. Li C, Guo Y, Liu Y, Cheng J, Zhang W. Hysteroscopic and laparoscopic management of uterine defects on previous cesarean delivery scars. J Perinat Med. 2014;42(3):363–70.
18. Feng Y-L, Li M-X, Liang X, Li X-M. Hysteroscopic Treatment of Postcesarean Scar Defect. J Minim Invasive Gynecol. 2012;19(4):498–502.
19. Gubbini G, Centini G, Nascetti D, Marra E, Moncini I, Bruni L, et al. Surgical Hysteroscopic Treatment of Cesarean-Induced Isthmocele in Restoring Fertility: Prospective Study. J Minim Invasive Gynecol.
011;18(2):234–7.
20. Raimondo G, Grifone G, Raimondo D, Seracchioli R, Scambia G, Masciullo V. Hysteroscopic Treatment of Symptomatic Cesareaninduced Isthmocele: A Prospective Study. J Minim Invasive Gynecol. 2015;22(2):297–301.
21. Muzii L, Domenici L, Lecce F, Feliciantonio MDI, Frantellizzi R, Marchetti C, et al. Clinical outcomes after resectoscopic treatment of cesarean-induced isthmocele: a prospective case-control study. Eur Rev Med Pharmacol Sci. 2017;21(15):3341-3346.
22. Cohen SB, Mashiach R, Baron A, Goldenberg M, Schiff E, Orvieto R, et al. Feasibility and efficacy of repeated hysteroscopic cesarean niche resection. Eur J Obstet Gynecol Reprod Biol. 2017;217:12–7.
23. Florio P, Filippeschi M, Moncini I, Marra E, Franchini M, Gubbini G. Hysteroscopic treatment of the cesarean-induced isthmocele in restoring infertility. Curr Opin Obstet Gynecol. 2012;24(3):180–6.
24. Tanimura S, Funamoto H, Hosono T, Shitano Y, Nakashima M, Ametani Y, et al. New diagnostic criteria and operative strategy for cesarean scar syndrome: Endoscopic repair for secondary infertility caused by cesarean scar defect. J Obstet Gynaecol Res. 2015;41(9):1363–9.
25. Tsuji S, Kimura F, Yamanaka A, Hanada T, Hirata K, Takebayashi A, et al. Impact of hysteroscopic surgery for isthmocele associated with cesarean scar syndrome. J Obstet Gynaecol Res. 2018 Jan;44(1):43-48.
26. Brown K, Tkacz Z. Hysteroscopic and laparoscopic management of caesarean scar (niche) defects in symptomatic patients. J Obstet Gynaecol Res. 2018; 38(5):730.
27. Api M, Boza A, Gorgen H, Api O. Should cesarean scar defect be treated laparoscopically? A case report and review of the literature. J Minim Invasive Gynecol. 2015;22(7):1145–52. 28. Marotta ML, Donnez J, Squifflet J, Jadoul P, Darii N, Donnez O. Laparoscopic repair of post-cesarean section uterine scar defects diagnosed in nonpregnant women. J Minim Invasive Gynecol. 2013;20(3):386–91.
29. Dosedla E, Calda P. Outcomes of laparoscopic treatment in women with cesarean scar syndrome. Med Sci Monit. 2017;23:4061–6.
30. Donnez O, Donnez J, Orellana R, Dolmans MM. Gynecologicaland obstetrical outcomes after laparoscopic repair of a cesarean scar defect in a series of 38 women. Fertil Steril. 2017;107(1):289– 96.
31. Giorgio A, Buggio L, Berlanda N, Vercellini P. Laparoscopic repair of a symptomatic post cesarean isthmocele: a video case report. Fertil Steril. 2017;107(6):e17-e18.
32. Urman B, Arslan T, Aksu S, Taskiran C. Laparoscopic Repair of Cesarean Scar Defect “Isthmocele.” J Minim Invasive Gynecol. 2016;23(6):857-858.
33. Ciebiera M, Jakiel G, Sałbuszewska-Jóźwiak A. Laparoscopic correction of the uterine muscle loss in the scar after a Caesarean section delivery. Wideochir Inne Tech Maloinwazyjne. 2013;8(4):342–345.
34. Bakavičiūtė G, Špiliauskaitė S, Meškauskienė A, Ramašauskaitė D. Laparoscopic repair of the uterine scar defect - successful treatment of secondary infertility: a case report and literature review. Acta Med Litu. 2016;23(4):227–231.
35. Mahmoud MS, Nezhat FR. Robotic-assisted laparoscopic repair of a cesarean section scar defect. J Minim Invasive Gynecol. 2015;22(7):1135–6.
36. Chen Y, Chang Y, Yao S. Transvaginal management of cesarean scar section diverticulum: a novel surgical treatment. Med Sci Monit. 2014;20:1395–9.
37. Zhang Y. A Comparative Study of Transvaginal Repair and Laparoscopic Repair in the Management of Patients With Previous Cesarean Scar Defect. J Minim Invasive Gynecol. 2016;23(4):535– 41.
38. Zhou J, Yao M, Wang H, Tan W, Chen P, Wang X. Vaginal Repair of Cesarean Section Scar Diverticula that Resulted in Improved Postoperative Menstruation. J Minim Invasive Gynecol. 2016;23(6):969–78.
39. Luo L, Niu G, Wang Q, Xie HZ, Yao SZ. Vaginal Repair of esarean Section Scar Diverticula. J Minim Invasive Gynecol. 2012;19(4):454–8.
40. Pomorski M, Fuchs T, Rosner-Tenerowicz A, Zimmer M. Sonographic evaluation of surgical repair of uterine cesarean scar defects. J Clin Ultrasound [Internet]. 2017;45(8):455–60. Disponible en:
ttps://www.ncbi.nlm.nih.gov/pubmed/28186617
41. Schepker N, Garcia-Rocha G-J, von Versen-Höynck F, Hillemanns P, Schippert C. Clinical diagnosis and therapy of uterine scar defects after caesarean section in non-pregnant women. Arch Gynecol Obstet. 2015 Jun 17;291(6):1417–23. Disponible en: https://www.ncbi.nlm.nih.gov/pubmed/25516174
42. Liu SJ, Lv W, Li W. Laparoscopic repair with hysteroscopy of cesarean scar diverticulum. J Obstet Gynaecol Res [Internet]. 2016;42(12):1719–23. Disponible en: https://obgyn.onlinelibrary. wiley.com/doi/abs/10.1111/jog.13146
43. Masuda H, Uchida H, Maruyama T, Sato K, Sato S, Tanaka M,
et al. Successful treatment of atypical cesarean scar defect
using endoscopic surgery. BMC pregnancy childb [Internet].
2015;15:342. Disponible en: https://www.ncbi.nlm.nih.gov/pmc/
articles/PMC4687144/
44. Nirgianakis K, Oehler R, Mueller M. The Rendez-vous technique
for treatment of caesarean scar defects: a novel combined
endoscopic approach. Surg Endosc [Internet]. 2016;30(2):770–1.
Disponible en: https://www.ncbi.nlm.nih.gov/pubmed/26104791
2. Departamento Administrativo Nacional de Estadística (DANE). Nacimientos 2015. Cuadro 4. Nacimientos por tipo de parto según departamento de ocurrencia y sitio del parto. 2017.
3. Tulandi T, Cohen A. Emerging manifestations of cesarean scar defect in reproductive-aged women. J Minim Invasive Gynecol. 2016;23(6):893–902.
4. Vervoort A, Van der Voet L, Hehenkamp W, Thurkow A, van Kesteren P, Quartero H, et al. Hysteroscopic resection of a uterine caesarean scar defect (niche) in women with postmenstrual spotting: a
andomised controlled trial. BJOG An Int J Obstet Gynaecol. 2018;125(3):326-334.
5. Martin JA, Hamilton BE, Osterman MJKS, Driscoll AK, Mathews TJ. National Vital Statistics Reports. 2017;66(1).
6. Organización Panamericana de la Salud, Organización Mundial de la Salud. La cesárea solo debería realizarse cuando sea medicamente necesaria. 2015.
7. Sipahi S, Sasaki K, Miller CE. The minimally invasive approach to the symptomatic isthmocele - what does the literature say? A step-by-step primer on laparoscopic isthmocele - excision and repair. Curr Opin bstet Gynecol. 2017;29(4):257–65.
8. van der Voet L (Lucet) F, Limperg T, Veersema S, Timmermans A, Bij de Vaate AMJ, Brölmann HAM, et al. Niches after cesarean section in a population seeking hysteroscopic sterilization. Eur J Obstet Gynecol Reprod Biol. 2017;214:104–8.
9. Benedetti O, Agudelo C, Rodríguez R, Miranda Á, Rodríguez H, Castro C. Prevalencia de istmocele en el Hospital de San José de Bogotá, Colombia. Rev Chil Obstet Ginecol. Sociedad Chilena de Obstetricia y Ginecología; 2016 Dec;81(6):465–72.
10. Tower AM, Frishman GN. Cesarean Scar Defects: An Underrecognized Cause of Abnormal Uterine Bleeding and Other Gynecologic Complications. J Minim Invasive Gynecol. 2013;20(5):562–72.
11. Wu X, Lin R, Yuan Y, He Y, Xu C, Hu W, et al. A comparison of the effects of two different treatment methods on cesarean section scar diverticulum: The surgical repair of cesarean scars via combined laparoscopy and hysteroscopy vs. cyclic estrogen/progesterone therapy. Int J Clin Exp Med. 2017;10(4):7144–50
12. Van Der Voet LF, Vervoort AJ, Veersema S, Bijdevaate AJ, Brölmann HAM, Huirne JAF. Minimally invasive therapy for gynaecological symptoms related to a niche in the caesarean scar: A systematic review. BJOG An Int J Obstet Gynaecol. 2014;121(2):145–56.
13. Setubal A, Alves J, Osório F, Guerra A, Fernandes R, Albornoz J, et al. Treatment for Uterine Isthmocele, a Pouch-Like Defect at the Site of Cesarean Section Scar. J Minim Invasive Gynecol. 2018;25(1):38-46.
14. Futyma K, Gałczyński K, Romanek K, Filipczak A, Rechberger T. When and how should we treat cesarean scar defect - isthmocoele? Ginekol Pol. 2016;87(9):664–8.
15. Li C, Tang S, Gao X, Lin W, Han D, Zhai J, et al. Efficacy of Combined Laparoscopic and Hysteroscopic Repair of Post- Cesarean Section Uterine Diverticulum: A Retrospective Analysis. Biomed Res Int. 2016;2016(5):1-6.
16. Zhang X, Yang M, Wang Q, Chen J, Ding J, Hua K. Prospective evaluation of five methods used to treat cesarean scar defects. Int J Gynaecol Obstet. 2016;134(3):336–9.
17. Li C, Guo Y, Liu Y, Cheng J, Zhang W. Hysteroscopic and laparoscopic management of uterine defects on previous cesarean delivery scars. J Perinat Med. 2014;42(3):363–70.
18. Feng Y-L, Li M-X, Liang X, Li X-M. Hysteroscopic Treatment of Postcesarean Scar Defect. J Minim Invasive Gynecol. 2012;19(4):498–502.
19. Gubbini G, Centini G, Nascetti D, Marra E, Moncini I, Bruni L, et al. Surgical Hysteroscopic Treatment of Cesarean-Induced Isthmocele in Restoring Fertility: Prospective Study. J Minim Invasive Gynecol.
011;18(2):234–7.
20. Raimondo G, Grifone G, Raimondo D, Seracchioli R, Scambia G, Masciullo V. Hysteroscopic Treatment of Symptomatic Cesareaninduced Isthmocele: A Prospective Study. J Minim Invasive Gynecol. 2015;22(2):297–301.
21. Muzii L, Domenici L, Lecce F, Feliciantonio MDI, Frantellizzi R, Marchetti C, et al. Clinical outcomes after resectoscopic treatment of cesarean-induced isthmocele: a prospective case-control study. Eur Rev Med Pharmacol Sci. 2017;21(15):3341-3346.
22. Cohen SB, Mashiach R, Baron A, Goldenberg M, Schiff E, Orvieto R, et al. Feasibility and efficacy of repeated hysteroscopic cesarean niche resection. Eur J Obstet Gynecol Reprod Biol. 2017;217:12–7.
23. Florio P, Filippeschi M, Moncini I, Marra E, Franchini M, Gubbini G. Hysteroscopic treatment of the cesarean-induced isthmocele in restoring infertility. Curr Opin Obstet Gynecol. 2012;24(3):180–6.
24. Tanimura S, Funamoto H, Hosono T, Shitano Y, Nakashima M, Ametani Y, et al. New diagnostic criteria and operative strategy for cesarean scar syndrome: Endoscopic repair for secondary infertility caused by cesarean scar defect. J Obstet Gynaecol Res. 2015;41(9):1363–9.
25. Tsuji S, Kimura F, Yamanaka A, Hanada T, Hirata K, Takebayashi A, et al. Impact of hysteroscopic surgery for isthmocele associated with cesarean scar syndrome. J Obstet Gynaecol Res. 2018 Jan;44(1):43-48.
26. Brown K, Tkacz Z. Hysteroscopic and laparoscopic management of caesarean scar (niche) defects in symptomatic patients. J Obstet Gynaecol Res. 2018; 38(5):730.
27. Api M, Boza A, Gorgen H, Api O. Should cesarean scar defect be treated laparoscopically? A case report and review of the literature. J Minim Invasive Gynecol. 2015;22(7):1145–52. 28. Marotta ML, Donnez J, Squifflet J, Jadoul P, Darii N, Donnez O. Laparoscopic repair of post-cesarean section uterine scar defects diagnosed in nonpregnant women. J Minim Invasive Gynecol. 2013;20(3):386–91.
29. Dosedla E, Calda P. Outcomes of laparoscopic treatment in women with cesarean scar syndrome. Med Sci Monit. 2017;23:4061–6.
30. Donnez O, Donnez J, Orellana R, Dolmans MM. Gynecologicaland obstetrical outcomes after laparoscopic repair of a cesarean scar defect in a series of 38 women. Fertil Steril. 2017;107(1):289– 96.
31. Giorgio A, Buggio L, Berlanda N, Vercellini P. Laparoscopic repair of a symptomatic post cesarean isthmocele: a video case report. Fertil Steril. 2017;107(6):e17-e18.
32. Urman B, Arslan T, Aksu S, Taskiran C. Laparoscopic Repair of Cesarean Scar Defect “Isthmocele.” J Minim Invasive Gynecol. 2016;23(6):857-858.
33. Ciebiera M, Jakiel G, Sałbuszewska-Jóźwiak A. Laparoscopic correction of the uterine muscle loss in the scar after a Caesarean section delivery. Wideochir Inne Tech Maloinwazyjne. 2013;8(4):342–345.
34. Bakavičiūtė G, Špiliauskaitė S, Meškauskienė A, Ramašauskaitė D. Laparoscopic repair of the uterine scar defect - successful treatment of secondary infertility: a case report and literature review. Acta Med Litu. 2016;23(4):227–231.
35. Mahmoud MS, Nezhat FR. Robotic-assisted laparoscopic repair of a cesarean section scar defect. J Minim Invasive Gynecol. 2015;22(7):1135–6.
36. Chen Y, Chang Y, Yao S. Transvaginal management of cesarean scar section diverticulum: a novel surgical treatment. Med Sci Monit. 2014;20:1395–9.
37. Zhang Y. A Comparative Study of Transvaginal Repair and Laparoscopic Repair in the Management of Patients With Previous Cesarean Scar Defect. J Minim Invasive Gynecol. 2016;23(4):535– 41.
38. Zhou J, Yao M, Wang H, Tan W, Chen P, Wang X. Vaginal Repair of Cesarean Section Scar Diverticula that Resulted in Improved Postoperative Menstruation. J Minim Invasive Gynecol. 2016;23(6):969–78.
39. Luo L, Niu G, Wang Q, Xie HZ, Yao SZ. Vaginal Repair of esarean Section Scar Diverticula. J Minim Invasive Gynecol. 2012;19(4):454–8.
40. Pomorski M, Fuchs T, Rosner-Tenerowicz A, Zimmer M. Sonographic evaluation of surgical repair of uterine cesarean scar defects. J Clin Ultrasound [Internet]. 2017;45(8):455–60. Disponible en:
ttps://www.ncbi.nlm.nih.gov/pubmed/28186617
41. Schepker N, Garcia-Rocha G-J, von Versen-Höynck F, Hillemanns P, Schippert C. Clinical diagnosis and therapy of uterine scar defects after caesarean section in non-pregnant women. Arch Gynecol Obstet. 2015 Jun 17;291(6):1417–23. Disponible en: https://www.ncbi.nlm.nih.gov/pubmed/25516174
42. Liu SJ, Lv W, Li W. Laparoscopic repair with hysteroscopy of cesarean scar diverticulum. J Obstet Gynaecol Res [Internet]. 2016;42(12):1719–23. Disponible en: https://obgyn.onlinelibrary. wiley.com/doi/abs/10.1111/jog.13146
43. Masuda H, Uchida H, Maruyama T, Sato K, Sato S, Tanaka M,
et al. Successful treatment of atypical cesarean scar defect
using endoscopic surgery. BMC pregnancy childb [Internet].
2015;15:342. Disponible en: https://www.ncbi.nlm.nih.gov/pmc/
articles/PMC4687144/
44. Nirgianakis K, Oehler R, Mueller M. The Rendez-vous technique
for treatment of caesarean scar defects: a novel combined
endoscopic approach. Surg Endosc [Internet]. 2016;30(2):770–1.
Disponible en: https://www.ncbi.nlm.nih.gov/pubmed/26104791
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